The hip pain map: what pain location says about the cause

You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. And now, your host. Hey everyone, this is your co-host, Sebastian, with the Restoring Human Movement podcast. Thanks for joining the show with me today. If you're an active individual, such as a runner or somebody who likes to play recreational sports, you're in the right podcast. As we tend to not try to scare you out of doing stuff, your body's pretty resilient, but the problem is a lot of people are scared to use their body.

They've been told that things are broken and damaged, and they're not really aware that they can actually help their body find ways to work around some of these problems that they've had. You're not destined to have pain forever, and you'll probably get back into your activity using a little bit of guidance. So today, we are going to cover one of the topics that I am probably going to do on one of our YouTube videos really soon. If you have not seen our YouTube channel, we literally have thousands of videos on various topics, such as sports hernias, hip impingement, plantar fasciitis, condomalace patella, runner's knee, even some of the upper extremity ones, too.

But we really like to share information about lower extremity conditions or lower quarter conditions, like lower back and downward. Now, one of the things that I'd seen recently, and then we are going to do a video on, are locations of the knee, of the pain, and how that can give a good insight of what the diagnosis is. I liked one of the YouTube videos I saw. I didn't completely agree with it, so I'm going to make one of my own to give more insight from what we've seen here. But I think I would like to extrapolate that to a hip and groin now. There are some areas that are common where people have hip or groin pain to give you a better idea of what people are meaning.

Because everybody has different things when they say hip. Some people mean the front. Some people say the back of the hip or the buttocks. Some people correct me and say, no, the hip is in the front side. You're right. The hip is in the front side. But the last person I saw, they said the hip is in the back side. Really, the hip is deep. The region of the hip is the whole area. The back side, we can call the buttocks. The front side, a lot of people call it the groin. And the side of the hip, kind of the point of the hip, where you would lay if you laid on your side. That area, the anatomical term is the trochanter.

It's the trochanter of the femur. So we're going to be talking about all those areas today and pain into those areas and what that could mean. Now, the one area in the front, which is into the crease of the hip, can be more possible that is actually hip joint pathology. It can be a labral tear or fray. And I'll describe how these things are different here in a moment. It can be hip arthritis of various different types. But it can also be associated to things like sports hernias, which have a little bit more of lower abdominal or pubic bone aspect to it. So let's first start talking about this area by talking about the most common, which is going to be hip impingement.

A hip impingement, again, it's an internal hip pathology. It's a biomechanical one. Some people will say, no, you can't change hip impingement. Well, right, you can't change the bony structure. There's a cam, which is an oblong shape or egg-shaped femur head. And then there's a pincer type, which is an overgrowth of the pelvis or the rim that it attaches into. You're not going to change those parts and you don't need to change them. Usually you can do rehabilitation or structured exercise programming to change the biomechanics of the area. What I mean by that is if you change your strength and activation of some of your tissues, then you can actually change how the pelvis is oriented.

We've covered this in another podcast where I've talked about an anterior tilt has very much been related to increased pinching of the hip with less hip range of motion. So just squatting down, you'll feel it more sooner with an anterior tilted pelvis than a posterior one. So you can use certain exercises to help nudge forward some of the mechanics that would help out to desensitize hip impingement because you're not going to get rid of the bones or do you need to. But the area where it's commonly felt is in the front crease of the hip. Now, I mentioned labrums before. Labrum is a cartilage area of the hip.

It's like an O-ring. It's like a gasket. And it can get injured with prolonged exposure to in pinch of the hip, they say, but sometimes it's traumatic. But the key note on this is that it's not always symptomatic. There are people all over the place. I think I can find the research if need be, but I think if you searched asymptomatic labral tears NHL hockey and went into Google searches for it, you'd probably find the same article. I think it was free in public. It mentioned that 66% of labral tears found on proof of MRI don't have any symptoms associated to them at all. And one third do. So, although hip pain in the front of the hip and the crease of the hip can be from a labral tear, it doesn't always mean that it is either.

Now, if you've had a positive image finding of a labral tear, again, 66% chances you don't have any symptoms associated to it at all. But you may have other findings, like the range of motion is different. With hip impingement, like I mentioned earlier, sometimes the hip range of motion is a little different. But it's a little softer end feel. With labral tears or labral pathology that is actually not going to change and it's larger, people have more movement restrictions. Usually flexing the hip all the way up to the chest and internally rotating it or bringing the foot away from midline in this position can be stiff.

But it can be painful as well with either pathology. Now, the big difference between these two, because the location is very similar, is that the labral tear, if a symptom generator, is a painful clicking and popping or a clunk in the hip. And it'll feel like you have to physically move the hip into a different orientation to get away from the pain. It's a very big difference, a very different severity as well. And if you are that, then there's a chance you may be more of a candidate for a labral repair. Now, another one in the front of the hip is going to be hip arthritis. The most common one is the old age or weight-bearing arthritis, we call it is osteoarthritis.

There are some thoughts that it is family-oriented, like it'll be based upon your hereditary nature. But for a lot of people, it's just based upon overuse or it's going to be from poor mechanics or old injuries in the past. Usually, arthritis is associated more commonly with old injuries. So if you've had an old injury and you haven't really dealt with it, although it doesn't hurt, the body finds ways to build bone up around the area to support it, limit range of motion. And that's just long-term way of dealing with it. And if you've gotten to the point where you have hip arthritis, there may be a pinching pain in the front of the hip.

It won't travel elsewhere. If you have pain elsewhere, that's from the compensation from it, like tendinopathies and other things around the area, which are creating ways around getting stuck with the impingement from the arthritis. But there's a really definitive feeling when you examine someone with hip arthritis. It's what we call a Dremens sign. And so when you bring their knee to their chest, their knee actually kicks out. It's like there's no way you can bring the knee across midline or even straight up to the top. And it's a really hard infill. It feels like there's actually bone or concrete kind of feeling there.

So that is more a sign of hip arthritis. You may be more of a candidate for surgery if it's really bad and you can't find ways to rehab around it, but some people do. But I've noticed that when people actually have this like skipping, clunking, it's not clicking, it's not catching. It's like it almost feels like gravel skipping around in there. Those people are way more probable they're going to need a hip replacement. And they're actually going to fare very well from it. Hip replacements are pretty good nowadays. You still need some rehab before and after. But I've had plenty of people that I know who have had hip replacements for hip arthritis that was advanced.

And they've done really, really well. Now, those are the most common things in the front crease of the hip. And we can talk about some variants of it now. It's lower abdominal area or down in the pubic bone or down to the inner thigh area. Kind of like as it meets up into the pubic bone from the inner thigh. This is more classic of what we call a sports hernia. A sports hernia can be found in many different varieties down there. There can be an adductor dominant one. There can be a lower abdominal dominant one. Or you can have a classic one, which is more so just the pubic bone, the bone right above your private parts, which is where the abdominal area, the abdominal muscles, and the adductor tendons insert into.

Now, this is a very hard condition for a lot of people to solve, mainly because there's not a lot of help out there. This is something that we specialize here in Performance Place. We've seen literally hundreds and hundreds of people with this condition. We've seen them on virtual or telehealth. A lot of them fare very well. Some of them don't. I've seen people in person, or we've done a blend of it, where we've seen people in person, then we do the rest of telehealth, too. A lot of it is guidance-based, and we need to make sure that the person has the right exercises they're doing, but also making sure they're not doing the wrong ones.

A lot of people do too many adductor or sit-ups, dominant exercises, and they just challenge the tissue, which has already challenged too much, and they don't really give it a break. So this is something that it can resolve. If you've looked at some of our YouTube videos on Sportrinias, hopefully you've already gotten that aspect of it. And we do have a free giveaway, too. I'll link it in the description for this podcast. It's a book that I wrote on a Sportrinias. It's called the Fortrinias Recovery Program, Five Steps. And it outlines kind of how these mechanics go, as well as other variants you may have in the condition.

But if you do have this, and you feel like you've been dealing with a Sportrinias and don't have any guidance, read the book. But if you really want some help, we do have telehealth as well. And you can do a discovery session with us at 714-502-4243. It's very affordable and licensed in different states. So if you are suffering with that, feel free to reach out. Now, if you're dealing with pain in the side of the hip, around the trochanter, kind of where you put your hands if you were mad, this is often called trochanteric bursitis. But I'm going to throw a variant in here with you, just because just the location does not give all the story.

And as you can see with these other problems, it doesn't really give you the whole story either. I would venture to say that most people who have pain on the outer side of the hip don't actually have trochanteric bursitis. Because if we talk about the actual term bursitis, it means the bursa is inflamed. If the bursa is inflamed, it will be swollen. If it's not swollen, it's not this. But there's other things that can cause it. There's a tendinopathy or even a tear of one of the glute tendons, so the glute medias tendons that pops into that bony area. I saw a research paper back at one of the sports symposiums about 10 years ago where they talked about majority of people who have pain in the trochanter area actually have more of this than the actual bursitis.

And I would agree with that. For those people who don't have evidence of any bursitis on imaging and they don't have the actual tendon tear either or tendinopathy, a lot of these ones can actually be referred from the spine, believe it or not. It's really common from more of a higher lumbar distribution, which is going to be more L1, L2. Even L3 and some of the lower ones sometimes create some problems in the area. Or if you have an old L5-S1, sometimes the compensation around the old sticky L5-S1 can create problems in the area in regards to overuse with some of these tissues into the area. Now, these ones are pretty easy to solve.

I'd venture to say that as things get a little bit more to the backside of the hip, like the side of the hip is still kind of backside of the hip, if we're talking about this classification. Anything that's trochanter and backside, such as piriformis, glute, tendinopathies, SI joint type of pain, high hamstring tendinopathy type of locations where it's kind of in the buttocks area or in the backside of the boating aspect of the hip on the side. Most of these ones, quite honestly, are spinal referred. And I know it's going to be very hard to hear, but I will tell you that easily 90% of the people that we see with pain in this distribution are actually spine-referred symptoms.

Almost nobody I've ever met has had a SI joint sprain or strain. That is a very strong joint. I've only met one, and I've been in practice 15 years, and there's a handful of tests that you can do to confirm this or unconfirm this as well, so it's not just me spitballing things. And I have a colleague who he's been in practice for 10 years, and he's only found one as well. So 25 years of practice, we've only found two. But they could be, but most of the time that SI joint pain that you may be feeling is an indication of a possible spinal referral, even if you don't have spinal pain. And these are much easier to solve.

But you still could have things like piriformis syndrome. Yes, you could have that. It's in the deep buttocks area, but it's less common than you think. I'd gamble to say that of people with posterior pain into the hip or buttocks area, I'd say 90% are a good spine-referred. Maybe 5% is going to be like a piriformis type of scenario. And the rest of it is 5%. It's sort of like an odd variance of stuff. I met one person one time that had an obturator muscle tear in there as well. They were non-responders for typical rehabilitation for hips and spines because there was an obviously tear. They had trauma as well.

It was a very odd case. But the good news is that a lot of the spinal care or spinal rehabilitation I'm talking about, it's not adjusting. It's not always soft tissue work, although tissue work, like active release, can be very helpful if we're talking about the older conditions. Like if you've had this for 2, 3, 4 plus years, then you'll be more of a candidate for it. Tim Ferriss on his 5-hour body was a really, really popularized active release back in the day. And there was a big influx of people asking for it. And some of the people did respond well to it in my experience, but there was actually a fair amount of people who didn't.

And they were asking for a type of care that was not merited with their type of problem. If it was a discogenic referral, such as a disc herniation, creating the symptoms to the buttocks area, they weren't going to respond to active release, especially in the early onset stage of their injury. If it was older, yeah, they may be able to respond a little bit better. But usually something that will work a little bit better is something like McKenzie Precips or what we call neurodynamic treatment, which is going to be, we call them side openers. If you're looking online and looking for neurodynamics, they should be taught by someone named Michael Shacklock, which is, we kind of in the industry call them like the godfather of nerve treatments.

If you've experienced Stuart McGill's work before, this works really well for a lot of cases as well. Some spinal stability, some side bridges, some planks, some bird dogs usually work really well. But those, the McGill Big Three, which includes the curl up, can be a good starting point for a lot of people with this posterior hip pain. But it doesn't work for everybody because there's, and he'll tell you in his works that not all back cases are created equal, even though the symptom presentation is exactly the same. And so everybody's a little bit different with their tolerances. And for that reason, some of the exercises and treatments are a little bit different as well.

But I would venture to say that if you are having pain in the front, again, it could be those things. If you're in the inner part, in the inner thigh, you could have a sports hernia, but I didn't mention before that you could have like an adductor tendinopathy, which is less common than the sports hernia. If you have pain in the front side of the groin, I didn't mention the hip flexor tendinopathy, which is super rare, more hip flexor overuse. But again, that is still a rehab approach, not a surgical one or a deep tissue one as much as a rehab case. It can help to do some tissue work on it, but usually the hip flexor or even the adductor is working excessively for other tissues that are off.

So this is where rehab comes into play. We had a gentleman just today that he's had ongoing adductor pain, and so we actually had him deadlift. And so after doing a couple weeks of really good deadlifting form and coaching and adequate load, and he feels a lot better. And he said, I should have been doing this a long time ago. He's gotten back to running. He can do all of his lifting. He's very happy. He's like, well, shoot, if people just did a little bit of deadlifting, you think you guys would be out of business? Well, like, no, it would definitely make more people feel better. But this is not the answer for everybody, for every condition.

But it's a good example of how if you activate the glutes with good structure rehabilitation, then the hip flexors and the adductors go off. They do less work. And so rather than thinking of these things like overuse injuries, you should think of them as overutilization ones. And then we talked lastly about the side of the hip, how it can be more from the tendinopathy of the glute medius, but more so it's probably more referred from the spine. And most of the stuff from the backside of the hip, like the deep buttock stuff, that is a lot of times spine referred. And especially if you're having hamstring issues and calf ones and numbness and tingling and burning and stabbing and things going down the leg, even to the foot, like that's certainly going to be spine referred.

So if you guys are looking for help with this, reach out to us. We have consultations called Discovery Sessions, 714-502-4243. Or you can go on to our website, p2sportscare.com. We have online programs for a lot of the things we do podcasts on. And it's not because we're trying to, as some people say on the YouTube comments, is take advantage of people. I would rather give you structure. And if you guys can't afford one-on-one care, that's okay. But don't assume doing unstructured things is going to help you either. I would rather just you have a good guidance of reps, sets, intensities, and exercise structure.

And that's what we end up going on with some of our 12-week online programs. So if you're self-guided, if you're interested in them, they are, I've spent a lot of time on them. And I wholeheartedly believe in them, but they will never substitute one-on-one attention either. So if you guys are looking for help, please reach out. We'd love to do so. Subscribe to the podcast and take care.